The Governor of California
President pro Tempore of the Senate
Speaker of the Assembly
State Capitol
Sacramento, California 95814

Dear Governor and Legislative Leaders:

As required by Business and Professions Code section 2718, the California State Auditor presents this audit report concerning the Board of Registered Nursing’s (BRN) enforcement program. BRN is responsible for implementing and enforcing the Nursing Practice Act, which establishes the laws related to the licensure, practice, and discipline of nurses. BRN regulates over 420,000 licensed nurses who provide health care services to the public and, on average, receives about 7,500 complaints annually regarding licensed nurses and prospective nurse applicants. This report concludes that BRN’s inadequate oversight of its complaint resolution process resulted in significant delays, which allowed some nurses who may pose a risk to patient safety to continue practicing.

Our review found that BRN consistently failed to achieve the California Department of Consumer Affairs’ (Consumer Affairs) 18-month goal for processing complaints. During our review of 40 investigated complaints resolved between January 1, 2013, and June 30, 2016, BRN failed to resolve 31 of the 40 complaints within the 18-month goal. In addition, 15 of those 31 complaints took longer than 36 months to resolve. Further, BRN took longer than 48 months to resolve seven of those 15 complaints, six of which included allegations of patient harm resulting from a nurse’s actions. These delays primarily occurred because of BRN’s ineffective oversight of the complaint resolution process and its failure to move the complaints through the various stages of the process in a timely manner.

Delays such as these have contributed to a backlog of complaints. Specifically, as of the end of July 2016, we identified a backlog of more than 180 complaints that BRN had not yet assigned to one of its investigators. In fact, nearly 140 were pending assignment for more than 10 days and, of these, roughly 70 involved urgent- or high-priority allegations, such as patient death, harm, or criminal activity, and had been waiting to be assigned for an average of nearly 80 days. Unnecessary delays in the complaint resolution process enable nurses who are the subject of serious allegations to continue practicing and may risk patient safety.

Further, BRN lacks accurate data to assess the timeliness of its complaint resolution process as the system it uses for enforcement activities lacks adequate controls to ensure BRN staff members accurately enter information into the system regarding complaint status. As a result, we found errors when attempting to calculate the length of each stage in the complaint resolution process, and had to remove nearly 4,800, or 17 percent, of the complaints from our analysis due to these errors. Additionally, BRN did not always adhere to Consumer Affairs’ direction or state law requiring that it assign complaints categorized as urgent or high priority to Consumer Affairs’ Division of Investigation (DOI), and instead chose to investigate the complaints internally. By not referring these complaints to DOI’s sworn peace officers to investigate, BRN risks that appropriate attention and resources are not being directed at the most egregious complaints. As a result, it could be prolonging its complaint processing timelines and, more importantly, placing the public at a higher risk of potential harm. Finally, we found that BRN lacks a formal training program for its enforcement staff, and we believe this could be a contributing factor for the delays we identified in BRN’s processing of complaints.